November 28, 2015

Addressing Lapses in Professionalism

by Beth Flippin, Pharm.D., PGY1-Pharmacy Practice Resident, VA Maryland Health Care System

Professionalism in the health professions has been defined as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served”.1 Professionalism serves as the basis of a contract between patients and healthcare providers. Teaching professionalism has become a core concept in health professional education, both in the didactic and experiential setting. However, with advances in medical technology and increased utilization of social media, it can be difficult to ensure that learners are maintaining expected standards of professionalism.

Common Professional Lapses2
· Lack of initiative to assume responsibility / role
· Misrepresentation or falsification of actions / information
· Failure to take responsibility for actions
· Abuse of privileges
· Inadequate rapport with patients
· Insensitivity
· Disrespectful language
· Inappropriate interactions with groups
· Lack of professional appearance
So how should lapses in professionalism be addressed and corrected? One study published in the Academic Medicine Journal found that the most effective methods were to address lapses in a timely manner and to provide constructive feedback rather than punish the learner.3 Several tips for approaching learners who have a lapse in professionalism have been published.4  

Modeling professional behavior is one of the key remediation strategies.2 Learners mimic their preceptors, regardless of whether the behavior is appropriate or not. Modeling involves all aspects of behavior in the practice setting, from one-on-one interactions with other professionals, patients, and caregivers; interprofessional team interactions, such as rounds or peer discussions; maintaining privacy; appropriate documentation, and adherence to timelines. Everyone must be mindful of the presence of learners in the experiential learning settings, because learners are observing the actions and demeanor all practitioners in order to help develop their own professional identity. Modeling appropriate professional behavior by all members of the interprofessional team serves as a link between didactic teachings and practical experience.4

The next tip is to acknowledge the hidden curriculum.  Instructional regarding professionalism in preclinical years is sometimes contradicted by unprofessional behaviors observed in the clinical settings.5 These observations are not just of the learners’ direct preceptor, but medical attending physicians, residents, social workers, pharmacists, nurses and any other personnel involved in patient care. It is important to acknowledge that learner’s may, at times, receive conflicting messages regarding professionalism from their observations.  Having conversations with the learner about lapses in professionalism committed by more senior practitioners can be a simple way to address inappropriate professional behavior so that the learner isn’t left with the impression that such behaviors are acceptable.

It is also important to be familiar with the institution policies and procedures for addressing lapses in professionalism.4 The institution or department policy should have clear procedures for how information regarding lapses should be documented, who should receive the information, and what the potential consequences are. This is beneficial for both the learner and the preceptor, as the expectations and consequences are clearly outlined at the beginning of the learning experience.

The next set of tip involves data gathering and fact checking. It is very important to ensure you have objective evidence to support the perceived lapses in professionalism.4  Because learners often model their behaviors based on observations, it is important to gather information from multiple sources that have had interactions with the learner and can provide first person testimony, documentation, or evidence of the learner’s behavior. This can also help to identify potential reasons behind the lapse, as well as ways to address the lapse in the future.

It’s important to have an experienced educator or mentor available for advice when needed. This person should have experience with learners in different types of situations. It’s important to clearly articulate your questions to your peer, as well as state how the learner expectations where outlined. The trusted advisor can provide perspective and help develop the plan for providing feedback to the learner.4

Next the preceptor should be ready to have a conversation with the learner regarding their professional behaviors. During the encounter, remember to be a good listener. Learners should have the opportunity to voice their perceptions of the situation. At times, perceived lapses may be a result of lack of understanding or misinterpretation of their role.  Be sure conduct the conversation in an environment where the learner feels safe, somewhere private and discrete so that the learner does not feel that they are being publicly reprimanded. Be care in your word choices. Use a non-accusatory approach. You don’t want the learner to feel attacked or become defensive about their actions. The preceptor should present to the learner the objective evidence gathered, then allow time for the learner to reflect. The preceptor should provide direct and explicit feedback to the learner. The learner should leave the encounter with a clear understanding of why the behavior is considered a lapse and how to improve in the future.4

Finally, the preceptor should close the loop.4 Preceptors should help the learner make a behavior change by ensuring the learner develops his/her decision-making skills. The preceptor can present hypothetical situations and have the learner voice the steps necessary to make a decision.  This is a helpful way to develop these problem-solving and ethical reasoning skills. Helping learners to recognize the impact that their behaviors may have on patient outcomes can also be motivational.4 Learners should be encouraged to continuously think about professional values and ways to develop their skills.

Know when to call for back-up. There are always going to be situations or learners who are difficult or when unexpected issues emerge. It’s important for the preceptor to know his/her limitations.

Addressing lapses in professional behaviors can daunting. The right tools can help preceptors feel more confident in addressing these lapses. Preceptors should have a plan to effectively address professional lapses in a timely fashion. Professionalism is vital to building a trusting patient-provider relationship, so it is important that future practitioners are aware of the importance of professionalism and how lapses can negatively impact relationships with patients and colleagues.

  1. Gibbs, T.  The changing face of professionalism: Reflections in a cracked mirror. Medical Teacher. 2015; 37:9, 797-798
  2. Ainsworth, M. Medical Student Professionalism: Are we measuring the right behaviors? A comparison of professional lapses by students and physicians. Academic Medicine. 2006; 81(10); S83-S86
  3. Ziring, D. How do medical schools identify and remediate professionalism lapses in medical students? A study of U.S. and Canadian medical schools. Academic Medicine. 2015; 90:(7) 914-920
  4. Rougas. S et. Al. Twelve tips for addressing medical student and resident physician lapses in professionalism. Medical Teacher, 2015; 37:10, 901-907
  5. Goldstein, E. Professionalism in medical education: an institutional challenge. Academic Medicine, 2006:81(10); 871-876

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